Professional boundaries and medical records management

Curiosity about the purpose of a group with the intriguing name of the Misnomers Committee led to the discovery that, in the 1950s and early 1960s, the Medical Library Association attempted to change the name of another profession. Concerned about confusion between medical librarians and medical record librarians, MLA worked to take “librarian” out of the job title and the name of the professional organization of the other group. This column will describe those efforts, looking at them in light of the evolving interrelationship of library collections and clinical records. Furthermore, the initiative illustrates the importance to MLA of the definition of the boundaries of medical librarianship and its affiliation with other professions.

The first half-century of the history of MLA was largely determined by the medical profession. Physicians founded and led the association both to improve library collections and to develop a liberally educated medical practitioner. They engaged in library pursuits for a combination of reasons—professionalization of the medical profession, scientific advancements, and aspirations to scholarship. In addition to their efforts to distribute medical knowledge through libraries, they developed standardized tools for retrieval of all types of information, including indexes to the journal literature and organization of clinical records. The MLA members who were full-time librarians brought a divergent perspective to the association, but not until after World War II did they clearly assume leadership. MLA increasingly became a professional organization for librarians, with concerns for educational standards, career advancement, and improving the delivery of health information [1].

One of the first librarian members of MLA, Grace W. Myers of Massachusetts General Hospital's Treadwell Library, was also a pioneer in medical records management. In addition to being a force for introducing professional concerns of librarians into the affairs of MLA, she was instrumental in the founding of an association for medical record professionals. In 1912, she wrote of the link between library materials and patient records.

If there is a hospital library, records should be kept in close proximity to it, and, if possible, come under the supervision of the library. With theory and fact thus brought into close relation, an atmosphere is created of study and investigation which to the doctor has a value beyond estimate [2].

MLA leaders focused on inviting physicians to support the association, but in 1912 they also considered the possibility of including records personnel as members. Myers reported for a Committee on New Members, appointed to solicit new members from among those interested in the care of hospital records. Although the effort did not bear fruit, it did indicate a perception that medical records were relevant to the aims of the association—or at least a willingness to allow Myers to pursue her own vision. Only three of the nineteen individuals the committee approached even agreed to consider membership, but Myers recommended that the association advertise papers for the next annual meeting with topics that could awaken interest from these persons, such as “methods of cataloging hospital cases by diagnosis” and “methods of preserving hospital records” [3].

The same year, Myers started a local club of record clerks. Thirty years after the founding of MLA, the Association of Record Librarians of North America was established in 1928 to elevate the standards of clinical records in hospitals and other medical institutions. The association recognizes Myers as the inspiration and first president of the association, with a vision of a national organization for the standardization of records management [4]. In her history of MLA, Jennifer Connor contrasts the Association of Record Librarians with MLA. While MLA arose from the medical community in support of its libraries, the records society was formed by workers for occupational improvement. It focused on the conduct of individual members and advancement in education for the field of medical records [5].

Similar titles, different interests

By 1953, representatives of MLA and what was now named the American Association of Medical Record Librarians were meeting to study the use of the title of librarian and to consider substituting another name for the staff of record departments. A committee, rather awkwardly called the Joint Committee on the Clarification of the Title: Librarian, agreed on the confusion resulting from having two departments and two professional groups within the hospital organization with similar titles but different interests. However, MLA seemed to be more troubled by the overlap, taking the lead in proposing solutions to which the medical record librarians reacted. The MLA half of the committee suggested sixteen alternatives for the title of medical record librarian. The medical record librarians thought the project worthy of “long range study and research” but protested that none of the alternative names so far was suitable. The titles were not truly descriptive of their work, did not apply to all personnel, or were not appealing for recruitment. The ability to retain the use of the designation R.R.L. (Registered Record Librarian) was also a concern, and MLA made some attempt to come up with ideas with the same initials.

At the last minute, the medical record librarians surprised MLA when their executive board decided that the name would not be changed for “economic, education, and legal reasons,” but they promised to try to educate people about the distinction between the professions. The disappointed MLA members recommended disbanding the joint committee and appointing its own group to approach the problem from the point of view of education of pertinent groups [6–8]. The less diplomatic first draft of their conclusion referred to the abrupt attempt by the medical record group to shut off efforts to find a solution [9].

Why did MLA try so hard to clear up the confusion? A 1954 editorial in the Bulletin of the Medical Library Association by L. Margueriete Prime was titled “Too Many ‘Librarians’?” She regretted the “time and effort wastefully expended by misdirected phone calls, and mail, and books which go astray.” Possibly as part of the planned educational approach, she carefully described the duties of the medical record department and the medical library. The medical record department was an essential part of the hospital but “not so much through its own contribution to the care of the patient, as through the fact that it serves to coordinate the record of the contributions of other departments of such care.” The medical library, on the other hand, was “an independent department making its own contribution…to the care of the patient” by bringing the medical literature of the world to its constituents as needed [10]. In some smaller hospitals, the medical record department was also responsible for the library, adding to the misunderstanding.

A paper presented by Virginia Donley encouraged cooperation between the two departments and recommended that medical librarians be familiar with the medical record as the source of information in books and journals. According to the author, neither department contributed income to the institution or served the patient directly, but she described the work of the record department as custodial and statistical and the work of the library as educational. If the annoyance of the daily confusion could be removed, the two departments could “correlate their work in such a way as to contribute in much greater measure to the common objective of all hospital work—the best possible care to all patients” [11].

This subtle pride in the superiority of library work was also reflected in the argument that medical librarians had a longer history. Although the medical record organization was praised for its accomplishments, it was noted that it was comparatively youthful and that it was better to make the change now rather than let the confusion continue [12].

Bird-dogging title misuses

The MLA committee that succeeded the joint committee, the Misnomers Committee, carried on the efforts to resolve the confusion between the names. Its work proceeded on two fronts—bird-dogging misuses of the titles and communicating with the medical record association and other medical groups. The committee wrote letters whenever they noticed an error, including in the comic strip “Rex Morgan, M.D.” Helen Yast pointed out to the publishers that a character was performing duties of a medical librarian but that the strip was calling her a medical records librarian.

 I have faithfully followed Dr. Morgan's adventures in his office and in the hospital, feeling you were doing a good service for medicine and the paramedical fields. However the current episode with Dr. Malvern and Nancy Tripp makes me wonder how authentic your material is. Being a member of the library profession, I was pleased to see in the early sequences that you portrayed the medical librarian as an intelligent and attractive young woman. But in the December 1 strip, right outside the library door, you have a resident identify Miss Tripp as a “medical records librarian.” Again, in the December 20 strip, Dr. Morgan identifies her as “the new medical records librarian.” To set the record straight, I am enclosing photocopies of job descriptions for the medical records librarian and the medical librarian. Each job makes an important contribution to patient care, but by no stretch of the imagination are the two job titles interchangeable [13].

A more substantive error was made by the U.S. Department of Labor in its 1954 Job Guide for Medical Occupations. Under Medical Record Librarians, some of the information was accurate, but the entrance requirements and training were those for medical librarians and the sources for information listed the Medical Library Association [14]. The American Library Association's Hospital Libraries Division wrote to the Labor Department to protest [15], and MLA drafted a resolution requesting that future statements be submitted to the respective associations before publication [16].

MLA prematurely thought the issue was resolved. Thomas Keys mistakenly remembered that, as president in 1957–1958, he was able to convince the medical record librarians at least to drop librarians from their association name, and he quoted a congratulatory letter from Janet Doe [17]. Although the group did eventually become the American Medical Record Association in 1970, in the late 1950s a proposed bylaw amendment to change the name was apparently dropped when the American Medical Association's legal department objected to the similarity with its name [18–20].

In 1960, the Misnomers Committee tried to enlist the aid of the MLA Regional Groups. They asked members to review Prime's editorial to inform themselves about the issue and to tell others.

 If every member of each Regional Group would take advantage of every opportunity to explain the difference tactfully and courteously, notable progress could be made. This will require patient explanations, in day to day contacts, and carefully worded clarifications to those whose misunderstanding is evident from their writings [21].

The final chair of the Misnomers Committee, Stanley Truelson, reopened communication with the president of the American Association of Medical Record Librarians [22]. When she did not answer a letter for several months, he lamented the long-standing problem.

 What tyranny words seem to have over our lives! Instead of pressing on toward the higher goals of both our associations, we must spend our time fencing at titles, names, mere designations that only represent, but do not constitute, our mission…If you and your association are ready to conclude that librarians you are and librarians you shall remain, then…[p]erhaps it would be better for our association…to face up to reality…I am sure, however, that medical librarians will never give up trying to counteract the confusion through broadside educational campaigns or individual communications—our future as a recognized professional group is involved here [23].

Truelson concluded with what the medical record librarians could have been thinking themselves.

 The thought has occurred to me that possibly we are the ones who should consider changing names. But, somehow, I cannot see what else we could call ourselves except librarians…since that is what we are [24].

The following year, MLA disbanded the committee [25].

A more expansive view of libraries

More recently, MLA has taken a more expansive view of the role of libraries and the diversity of its membership, as well as the concept of information. Two events were particularly influential. In 1982, the Matheson report envisioned the network concept linking the world's knowledge base to practice knowledge bases, and it proposed the retooled library as a logical unit to perform the functions. Individual patient data would have multiple uses in different files, and data from many sources that would apply to any one patient could be tapped or transmitted [26].

The 1994 revision of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards was another singular development. It integrated the information management function, encompassing patient-specific information, aggregate and comparative patient data, and knowledge-based information (the traditional library collections and services), without specifying an organizational structure to accomplish the function [27, 28].

Ironically, the American Medical Record Association did change its name in 1991—to the American Health Information Management Association (AHIMA)—in an era when MLA was moving toward billing itself as the source for “quality information for improved health.” AHIMA represents professionals who work for “quality healthcare through quality information,” compiling and analyzing patient data and making it accessible to health care providers when it is needed most [29]. MLA recognized that AHIMA used the name change to assume an expanded role when health care plans required the integration of financial systems and medical records [30].

AHIMA's definition and adoption of terminology that health sciences librarians felt belonged to them occurred at a time when many professions staked their claim to roles in managing health information. The Information Age has blurred the lines among data, information, and knowledge, and made more of it directly accessible to more people. Health sciences librarians, rather than focusing on protests that other groups are assuming their titles, have worked to redefine the role of libraries, develop collaborative relationships, and build on the historical knowledge and skills of librarians.